Ilizarov Method for Wound Closure and Bony Union of an Open Grade IIIB

WWW.CRCPR-ONLINE.COM Case Rep Clin Pract Rev, 2004; 5(1): xxx-xxx Case Report

Received: 2003.01.10 Accepted: 2003.05.22 Ilizarov method for wound closure and bony union of Published: 2004.00.00 an open grade IIIB tibia fracture

John E. Mullen, M.D., S. Robert Rozbruch, M.D., Arkady Blyakher, M.D., David L. Helfet, M.D.

Limb Lengthening Service, Orthopedic Trauma Service, Hospital for Special Surgery, New York, New York

Summary

Background: The treatment of tibia fractures with a critical sized wound is complicated. When primary closure is not possible, the classic options are rotational or free flap coverage. Soft-tissue coverage is critical to avoid infection. There are instances when flap coverage is not an option. We present an alternative technique for simultaneous bone healing and soft tissue closure using the Ilizarov method. Case report: A grade IIIB open tibia fracture was treated with an Ilizarov external fixator. Wound debridement, removal of loose bone fragments and gradual compression across the fracture site led to bony shortening and union. Soft tissue transport led to secondary wound closure. An excellent anatomic and functional outcome resulted. Conclusions: This technique of bone and soft-tissue transport may prove useful in the treatment of tibia fractures with difficult to close wounds or for patients who are not candidates for flap coverage.

Key words: Ilizarov•tibia•wound Full-text PDF: http://www.crcpr-online.com/pub/vol_5/no_1/3389.pdf

Word count: 1506 Tables: - Figures: 8 References: 19

Author’s address: GS. Robert Rozbruch, M.D., Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, phone: (212) 606-1415, fax: (212) 774-2744, e-mail: [email protected]

1 Case Report

BACKGROUND

Open fractures of the tibial shaft are both common and may be fraught with complications. Malunion, delayed union, nonunion, and infection are all seen regularly after open tibia fractures [1,2,3,4,5]. The subcutaneous location of the tibia places the leg at risk for skin loss at the time of fracture. Delay in closure of open tibia wounds has been associated with an increased prevalence of late infection [6]. With any exposed tendon or bone, wound coverage becomes a necessity.

Soft tissue flaps are the most commonly employed method of obtaining wound coverage. Flap coverage can be performed with a local rotational muscle flap, a free vascularized muscle flap or a local fasciocutaneous flap [7]. The type of flap used is based on the location of the wound. In the proximal third of the tibia, a gastrocnemius rotational flap is used. In the middle third, soleus, medial gastrocnemius, and tibialis anterior rotational flaps have all been advocat- ed, while for wounds in the distal third of the tibia, a free vascularized muscle flap is required [8].

Open fractures of the tibia, with associated vascular injuries, have historically had a very poor outcome [9]. This poor prognosis has prompted some to call for early amputation in select cases [10].

Ilizarov external fixation has also proven to be a valuable method for treating open tibia fractures. The ability of the frame to stabilize a fracture, provide compression at the fracture site, and allow access to the soft tissues makes it an integral tool in the mana- gement of severe tibia fractures. Metaphyseal fractures with significant shaft extension and fractures with short periarticular fragments are examples of situations in which an Ilizarov frame is frequently employed [11]. Figure 1. Injury anteroposterior (AP) radiograph of tibia and fibula Recently, the Ilizarov technique has been used to close chronic soft tissue defects of the tibia. Soft tissue CASE REPORT has been transported along with bone to close large defects [12]. Skin traction employing hooks and an The patient is a 49-year-old man who was struck by Ilizarov frame has also been used with success to close a car while riding a motorcycle. The patient sustained tibial wounds [13]. This case report will discuss the a right intertrochanteric hip fracture, a right femoral closure of a 4 x 4.5 centimeter (cm) distal leg wound shaft fracture, a right tibial plateau fracture, a right over the subcutaneous surface of the tibia that grade IIIB open tibial shaft fracture of the distal one- resulted from an open grade IIIB tibia fracture [14]. third of the tibia, a right calcaneocubiod fracture The wound was closed with an Ilizarov frame utilizing dislocation, a right Lis Franc fracture dislocation and gradual compression across the segmental fracture multiple right metatarsal fractures (Figure 1). site and wound. This technique using closure, rather than coverage, may provide an answer for difficult During the patient’s trauma work-up he was noted to tibia wounds. have an absent dorsalis pedis pulse and first web space

2 Mullen J.E. et al. – Ilizarov Method for Wound Closure

Figure 2. Leg wound at the time of Ilizarov frame application Figure 3. Leg wound one month after Ilizarov frame application numbness. Angiography was done and showed from the wound, the hybrid external fixator was disruption of the anterior tibial artery at the level of removed, and an Ilizarov external fixator was placed the tibial shaft fracture. Other than a scalp laceration on the tibia. Gradual compression of 1-2 millimeter the remainder of the trauma work-up was negative. (mm)/day was started at the wound/fracture site and over the next two months complete wound healing The patient was brought to the operating room and occurred (Figures 2,3,4). One inch of shortening underwent an open reduction and internal fixation occurred as a result of the initial debridement of of his right hip, a retrograde nailing of his right femur, desiccated bone fragments and compression of the an open reduction and internal fixation of his tibial comminuted fracture. The fracture was fully healed plateau fracture and placement of a hybrid external and the frame removed at five months (Figures 5 and fixator on his right tibia. The distal tibia fracture was 6). At one year follow-up the patient had right knee severely comminuted with a large segmental fragment range of motion of 0 to 135º. He had 0º of dorsiflexion and significant medial bone loss (Figure 1). At the and 30º of plantarflexion of his right ankle. His right time of admission, the distal tibial wound was appro- ankle dorsiflexion strength was four out of five and ximately 3 cm in length with exposed bone that had plantarflexion strength was five out of five. He had no been stripped of its periosteum. The surrounding complaints of hypersensitivity or cold intolerance. The tissue was thin and poorly vascularized and would patient was then full weight bearing without pain and experience breakdown during the postoperative was wearing a one-inch shoe lift to account for his leg period. Over the next month the patient was brought length discrepancy. He then underwent an ipsilateral back to the operating room for repeat debridements femoral lengthening of one inch to equalize his leg of his right tibia, as well as fixation of his right foot lengths. At two year follow-up, he has full mobility of fractures, and a resection of his right first ray. After his knee. His ankle and foot continue to function well this time the patient was left with a 4.5 x 4 cm open with no change in mobility. wound on the anteromedial portion of his right distal tibia with exposed fragments of comminuted bone DISCUSSION in the wound. Different treatment options were considered to achieve wound closure and bony union, Open fractures of the tibia with associated vascular and a novel approach was selected. injury are a difficult problem to treat. Vascular injury impedes soft tissue healing and has been shown to The patient was brought back to the operating room double the rate of anastomotic thrombosis during free and his right tibia wound was once again debrided. All flap reconstruction [15]. Deep infection, malunion, loose, exposed, and desiccated bone was removed delayed union, and nonunion have all been reported

3 Case Report

Figure 4. Leg wound two months after Ilizarov frame application Figure 5. AP radiograph of distal tibia and fibula after union after these fractures [1,2,3,4,5]. Treatment options With comminuted, open fractures of the distal third of may be limited, especially with fractures of the distal the tibia open reduction internal fixation and third of the tibia. In this region, distally based muscle intramedullary nailing may have a limited role. Bone flaps and fasciocutaneous flaps have been used with grafting may used to fill bony defects but it has its own varying amounts of success [16,17]. The primary associated morbidity [18]. With these fractures, option for coverage of the distal third of the tibia is Ilizarov external fixation may be used to achieve a free flap. When a free flap is not possible or has fracture union as well as wound closure. New methods failed, a cross-leg flap remains a useful option despite employing the Ilizarov technique may provide distinct its significant morbidity. advantages regarding the soft tissues. These advantages may include fewer indications for rotational and free flap wound coverage, less need for amputation, fewer infections, and shorter treatment time. In addition the surgery is performed using percutaneous technique with limited exposure to minimize soft tissue trauma. Postoperatively the frame allows adjustability as well early weight bearing through axially dynamized stable fixation [19].

Defects in the bone and soft tissue of the tibia may be treated with debridement followed by an acute or gradual approximation of the bone ends. Compression is then employed at the fracture site, which also provides closure of the soft tissue defect. This monofocal approach leads to some limb shortening as in the present case [11] (Figure 7).

Alternatively, a bifocal approach can be used [11] (Figure 8). The bone and soft tissue defect is treated with compression and shortening at the injury site with a synchronized distraction and lengthening at a level outside the zone of injury. This technique Figure 6. Lateral radiograph of the distal tibia and fibula after union achieves union while simultaneously treating any

4 Mullen J.E. et al. – Ilizarov Method for Wound Closure

Figure 7. Bone and soft tissue defect treated with monofocal method preexisting or iatrogenic limb length discrepancy. A low energy percutaneous osteotomy is performed in the proximal metaphysis of the tibia. Compression and shortening are employed at the fracture/wound while simultaneous distraction and lengthening of the osteotomy occurs. The tibial wound may be closed acutely or subacutely with the aid of the compression that is occurring at the fracture site.

In the present case, the goal was to obtain wound closure and fracture healing. The concept of the previously mentioned techniques was used, but simultaneous proximal tibia lengthening was precluded because of an associated tibial plateau fracture Figure 8. Bone and soft tissue defect treated with bifocal method and the presence of a plate. It was decided that lengthening, if necessary, would be performed after all CONCLUSIONS healing had occurred. Lengthening of his femur was done one year later to equalize his leg lengths and The Ilizarov external fixator has long been established avoid his previously traumatized tibia. as an effective tool for treating difficult tibia fractures and it may prove to equally effective in dealing with Our experience is limited, but this may serve as an the soft tissue aspect of these injuries. Utilizing com- additional tool in the treatment of open tibia pression at the fracture site will not only promote fractures. As far as we can determine this technique bone healing, but may allow closure of wounds that has not been previously published. previously required flap coverage or amputation.

REFERENCES

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